HospitalInspections.org

Based on observation and interview, the facility failed to maintain smoke barriers within the facility in accordance with the National Fire Protection Association (NFPA) Standard 101, 2000 edition, Section 19.3.7.3. Smoke barriers shall be continuous from outside wall to outside wall from floor to roof and extending through all concealed spaces and attics. Smoke barriers shall have a fire resistance rating of not less than ½ hour. This facility had a capacity of 29 residents and a census of 15 residents on the date of inspection.
Findings Include:
Observations and staff interviews on 02/29/16 at 2:14 pm, revealed a hole (approximately 2x2 inches in size) located above the barrier doors at the Nursery Access.
Maintenance Staff A verified this observation.

Based on observation and interview, the facility failed to maintain/provide the 1 hour fire resistant rated construction in hazardous rooms from other compartments in accordance with Section 19.3.5.4 of the National Fire Protection Association (NFPA) Standard 101, Life Safety code, 2000 edition. This facility had a capacity of 29 residents and a census of 15 residents on the date of inspection.
Findings Include:
1. Observations and staff interviews on 02/29/16 at 12:48 pm, revealed the door to the Clean Utility Room in ER would not close and latch properly when tested.
2. Observations and staff interviews on 02/29/16 at 1:00 pm, revealed a chair that was preventing the proper closing of the door to the Oxygen Storage Room.
3. Observations and staff interviews on 02/29/16 at 1:45 pm, revealed the door to the Respiratory Therapy Storage Room was not equipped with self closing hardware.
Maintenance Staff A verified this observation.

Based on observation and interview, the facility failed to maintain exits in smoke zones easily accessible at all times in accordance with Section 19.2.1 and Section 7.1 of the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 edition. This deficient practice would affect approximately one of six smoke zones. This facility had a capacity of 29 residents and a census of 15 residents on the date of inspection.
Findings Include:
Observations and staff interviews on 02/29/16 at 10:15 pm, revealed several retail items and portable shelving being displayed for sale in the Main Entrance Corridor.
Maintenance Staff A verified this observation.

Based on record review and interview, the facility failed to provide the required bi-annual sensitivity testing of the smoke detectors throughout the facility to ensure the sensitivity of the detectors were within the manufacturer ' s specification as required by Section 9.6.1.3 of the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 edition and NFPA 72, National Fire Alarm Code, 1999 edition. This deficient practice would affect all residents within the facility. This facility had a capacity of 29 residents and a census of 15 residents on the date of inspection.
Findings Include:
Observations, record review and staff interviews on 02/29/16 at 10:55 am, revealed the facility did not produce documentation of a current sensitivity test of its fire alarm system.
Maintenance Staff A verified this observation.

Based on observation, record review, and interview, the facility failed to provide/maintain the building ' s sprinkler system in reliable operating condition and/or maintain proper testing and maintenance in smoke zones in accordance with the National Fire Protection Association (NFPA) Standard 25, Inspections, Testing, and Maintenance of Sprinkler Systems, 1998 edition, the NFPA Standard 13, Standard for the Installation of Sprinkler Systems, 1998 edition, and Sections 19.7.6 of the NFPA Standard 101, Life Safety Code, 2000 edition. This deficient practice would affect the entire facility. This facility had a capacity of 29 patiences and a census of 15 patiences on the date of inspection.
Findings Include:
1. Observations, record review and staff interview on 02/29/16 at 10:45am, revealed the facility did not have documentation that a quarterly sprinkler inspection had been conducted for the fourth quarter of 2015.
2. Observations and staff interview on 02/29/16 at 1:31pm, revealed foreign material on the sprinkler head located in the Administrative Assistants Office.
3. Observations and staff interview on 02/29/16 at 1:53 pm, revealed an obstructed sprinkler head located in the Pool Mechanical Room.
4. Observations and staff interview on 02/29/16 at 2:21pm, revealed a loose escutcheon plate on the sprinkler head located in Room 215 in ICU.
Maintenance Staff A verified this observation.

Based on observation and interview, the facility failed to maintain the building ' s electrical wiring and equipment in smoke zones in accordance with the National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition. This facility had a capacity of 29 residents and a census of 15 residents on the date of inspection.
Findings Include:
1. Observations and staff interview on 02/29/16 at 1:15pm, revealed a missing junction box cover located in the IT Room.
2. Observations and staff interview on 02/29/16 at 1:24 pm, revealed items stored within 36 inches of the electric panel located in the Kitchen Chemical Storage Room.
3. Observations and staff interview on 02/29/16 at 1:40pm, revealed a lamp plugged into a surge protector located in the Performance Improvement Office.
4. Observations and staff interview on 02/29/16 at 1:20 pm, revealed a lamp plugged into a surge protector located in the Nursing Directors Office.
Maintenance Staff A verified these observations.

Based on observation and interview, the facility failed to maintain smoke barriers within the facility in accordance with the National Fire Protection Association (NFPA) Standard 101, 2000 edition, Section 19.3.7.3. Smoke barriers shall be continuous from outside wall to outside wall from floor to roof and extending through all concealed spaces and attics. Smoke barriers shall have a fire resistance rating of not less than ½ hour. This facility had a capacity of 29 residents and a census of 15 residents on the date of inspection.
Findings Include:
Observations and staff interviews on 02/29/16 at 2:14 pm, revealed a hole (approximately 2x2 inches in size) located above the barrier doors at the Nursery Access.
Maintenance Staff A verified this observation.

Based on observation and interview, the facility failed to maintain/provide the 1 hour fire resistant rated construction in hazardous rooms from other compartments in accordance with Section 19.3.5.4 of the National Fire Protection Association (NFPA) Standard 101, Life Safety code, 2000 edition. This facility had a capacity of 29 residents and a census of 15 residents on the date of inspection.
Findings Include:
1. Observations and staff interviews on 02/29/16 at 12:48 pm, revealed the door to the Clean Utility Room in ER would not close and latch properly when tested.
2. Observations and staff interviews on 02/29/16 at 1:00 pm, revealed a chair that was preventing the proper closing of the door to the Oxygen Storage Room.
3. Observations and staff interviews on 02/29/16 at 1:45 pm, revealed the door to the Respiratory Therapy Storage Room was not equipped with self closing hardware.
Maintenance Staff A verified this observation.

Based on observation and interview, the facility failed to maintain exits in smoke zones easily accessible at all times in accordance with Section 19.2.1 and Section 7.1 of the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 edition. This deficient practice would affect approximately one of six smoke zones. This facility had a capacity of 29 residents and a census of 15 residents on the date of inspection.
Findings Include:
Observations and staff interviews on 02/29/16 at 10:15 pm, revealed several retail items and portable shelving being displayed for sale in the Main Entrance Corridor.
Maintenance Staff A verified this observation.

Based on record review and interview, the facility failed to provide the required bi-annual sensitivity testing of the smoke detectors throughout the facility to ensure the sensitivity of the detectors were within the manufacturer ' s specification as required by Section 9.6.1.3 of the National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2000 edition and NFPA 72, National Fire Alarm Code, 1999 edition. This deficient practice would affect all residents within the facility. This facility had a capacity of 29 residents and a census of 15 residents on the date of inspection.
Findings Include:
Observations, record review and staff interviews on 02/29/16 at 10:55 am, revealed the facility did not produce documentation of a current sensitivity test of its fire alarm system.
Maintenance Staff A verified this observation.

Based on observation, record review, and interview, the facility failed to provide/maintain the building ' s sprinkler system in reliable operating condition and/or maintain proper testing and maintenance in smoke zones in accordance with the National Fire Protection Association (NFPA) Standard 25, Inspections, Testing, and Maintenance of Sprinkler Systems, 1998 edition, the NFPA Standard 13, Standard for the Installation of Sprinkler Systems, 1998 edition, and Sections 19.7.6 of the NFPA Standard 101, Life Safety Code, 2000 edition. This deficient practice would affect the entire facility. This facility had a capacity of 29 patiences and a census of 15 patiences on the date of inspection.
Findings Include:
1. Observations, record review and staff interview on 02/29/16 at 10:45am, revealed the facility did not have documentation that a quarterly sprinkler inspection had been conducted for the fourth quarter of 2015.
2. Observations and staff interview on 02/29/16 at 1:31pm, revealed foreign material on the sprinkler head located in the Administrative Assistants Office.
3. Observations and staff interview on 02/29/16 at 1:53 pm, revealed an obstructed sprinkler head located in the Pool Mechanical Room.
4. Observations and staff interview on 02/29/16 at 2:21pm, revealed a loose escutcheon plate on the sprinkler head located in Room 215 in ICU.
Maintenance Staff A verified this observation.

Based on observation and interview, the facility failed to maintain the building ' s electrical wiring and equipment in smoke zones in accordance with the National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition. This facility had a capacity of 29 residents and a census of 15 residents on the date of inspection.
Findings Include:
1. Observations and staff interview on 02/29/16 at 1:15pm, revealed a missing junction box cover located in the IT Room.
2. Observations and staff interview on 02/29/16 at 1:24 pm, revealed items stored within 36 inches of the electric panel located in the Kitchen Chemical Storage Room.
3. Observations and staff interview on 02/29/16 at 1:40pm, revealed a lamp plugged into a surge protector located in the Performance Improvement Office.
4. Observations and staff interview on 02/29/16 at 1:20 pm, revealed a lamp plugged into a surge protector located in the Nursing Directors Office.
Maintenance Staff A verified these observations.